ALSD Formal Bullying Reporting form
This form is intended for reporting bullying incidences that occur in the Austintown Local School District.
Statement of Understanding: I acknowledge that by submitting this report I understand that harassment, bullying, and intimidation is defined by the Ohio Revised Code as “intentional written, verbal, graphic, physical or electronic act that a student or group of students exhibited toward the alleged victim more than once; and the behavior both causes mental or physical harm to the other student, and is sufficiently severe, persistent or pervasive that it creates an intimidating, threatening or abusive educational environment for the other student (ORC3313.666) and that false reports will result in disciplinary action pursuant to the Student Code of Conduct that may include, but not limited to: detention, suspension, and/or expulsion depending on the circumstances. *
Required
Date: *
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Form submitted by: *
Alleged Victim Name *
Your answer
Parent/Guardian Name *
Your answer
Address *
Your answer
City *
Your answer
State/Province/Region *
Your answer
Postal/Zip *
Your answer
Country *
Your answer
Phone Number *
Your answer
Grade *
Alleged offender name *
Your answer
Grade *
If there is more than one alleged offender, please list name and grade here. *
Your answer
Please list the name and grade of any witnesses. *
Your answer
Harassment Categories and Behaviors: Verbal Aggression - name calling, mocking, teasing, intimidating phone calls, spreading rumors, threats.Intimidation - getting in someone’s face, taking things, demanding money or items, hazing, etc. Emotional - excluding, tormenting, threatening gestures, ridicule, staring, etc. Physical Aggression - pushing, kicking, punching, slapping, tripping, pinching, spitting, etc. Sexual—touching, dirty jokes, flirting, asking out on dates after being told no, etc. Racial - comments or nicknames based upon physical, behavioral or cultural differences. Written - threatening or inappropriate notes or drawings. Electronic - threatening/intimidating Facebook comments, messages, wall posts, images, text messages, emails, etc. Please select one harassment category *
Please provide a detailed narrative description of the Harassment. If there is more than one Alleged Offender, describe each persons harassment behavior. *
Your answer
I acknowledge this report is accurate and contains factual information only and that I will be subject to discipline for false reporting in compliance with the policy of the Board of Education and the Student Handbook.I acknowledge that the administration will complete their investigation in compliance with policy and that any potential intervention and action will also be in compliance with policy and the individual rights of all of the involved students.I acknowledge that the Austintown Police Department and other law enforcement entities may be involved in matters pertaining to electronic, and other harassment occurrences, that take place outside of school or that involve the illegal distribution of images or in any other way are unlawful.I acknowledge that the district interventions may include, and are not limited to, the involvement of district employed Case Worker, Guidance Counselors, School Resource Officers, School Nurses, and other personnel where necessary.By entering my name below I acknowledge my full understanding and agreement of all of the statements listed above. *
Your answer
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